What is the recommended treatment for cephalgia (headaches)?

Treatment of Cephalgia (Headache)

The recommended treatment for headache depends critically on the headache type, but for the most common presentations—tension-type and migraine headaches—first-line therapy consists of ibuprofen 400 mg or acetaminophen 1000 mg for tension-type headache, and NSAIDs (ibuprofen 400-800 mg or naproxen 500-825 mg) or triptans for migraine, with the critical caveat that all acute medications must be limited to no more than 2 days per week to prevent medication-overuse headache. 1, 2

Tension-Type Headache Treatment

• Ibuprofen 400 mg or acetaminophen 1000 mg are recommended as first-line short-term treatment for tension-type headache. 1
• These medications should be taken at headache onset for maximum effectiveness. 2
• Limit use to no more than twice weekly to prevent medication-overuse headache. 1

Migraine Headache Treatment Algorithm

Mild to Moderate Migraine

• NSAIDs are first-line therapy: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg. 2, 3
• Acetaminophen 1000 mg is an alternative for patients with contraindications to NSAIDs, though it has a higher number needed to treat (NNT of 12 for 2-hour pain-free response). 4, 5
• Take medication early in the attack while pain is still mild for optimal efficacy. 2

Moderate to Severe Migraine

• Triptans are first-line therapy: oral sumatriptan 50-100 mg, rizatriptan, naratriptan, or zolmitriptan. 2, 6
• Combination therapy with triptan plus NSAID (e.g., sumatriptan 50-100 mg plus naproxen 500 mg) is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 2
• For rapid-onset migraine with nausea/vomiting, subcutaneous sumatriptan 6 mg provides the highest efficacy (70-82% response within 15 minutes, 59% pain-free by 2 hours). 2, 6, 7
• Intranasal options include sumatriptan 20 mg or zolmitriptan 5-10 mg when oral route is compromised. 1, 2, 7

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg or prochlorperazine 10 mg for nausea, which provides synergistic analgesia beyond antiemetic effects. 2, 8
• Antiemetics should be given 20-30 minutes before analgesics to enhance absorption. 2

Cluster Headache Treatment

Acute Treatment

• Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg are recommended for short-term treatment. 1
• Normobaric oxygen therapy (100% oxygen inhalation) is highly effective for acute cluster attacks. 1, 7
• Noninvasive vagus nerve stimulation is suggested for episodic cluster headache. 1

Preventive Treatment

• Galcanezumab is suggested for prevention of episodic cluster headache (but recommended against for chronic cluster headache). 1
• Verapamil (at least 240 mg/day) is commonly used for long-term prophylaxis, though evidence is insufficient for formal recommendation. 1, 7

Critical Medication-Overuse Headache Prevention

• All acute headache medications must be limited to no more than 2 days per week (not 2 doses, but 2 calendar days). 1, 2
• Medication-overuse headache occurs when acute medications are used ≥10 days/month for triptans or ≥15 days/month for NSAIDs, leading to daily or near-daily headaches. 2, 6
• If headaches occur more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency. 2, 9

Contraindications and Safety Considerations

Triptan Contraindications

• Triptans are contraindicated in patients with ischemic heart disease, previous myocardial infarction, Prinzmetal's angina, uncontrolled hypertension, cerebrovascular disease (stroke/TIA), or hemiplegic/basilar migraine. 6
• For patients with multiple cardiovascular risk factors but no known CAD, administer the first triptan dose in a medically supervised setting with ECG monitoring. 6
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, or MAO inhibitors. 6

NSAID Precautions

• Use NSAIDs cautiously in patients with renal impairment, history of GI bleeding, or cardiovascular disease. 2

Nonpharmacologic Adjuncts

• Physical therapy is suggested for management of tension-type, migraine, or cervicogenic headache. 1
• Aerobic exercise or progressive strength training is suggested for prevention of tension-type and migraine headache. 1
• Greater occipital nerve block is suggested for short-term treatment of migraine. 1

Common Pitfalls to Avoid

• Never allow patients to escalate acute medication frequency in response to treatment failure—this creates medication-overuse headache and worsens the underlying condition. 2, 9
• Do not use opioids or butalbital-containing compounds as first-line therapy; these should be reserved only when other medications cannot be used and abuse risk has been addressed. 1, 2
• Avoid patent foramen ovale closure or implantable sphenopalatine ganglion stimulators, as guidelines recommend against these interventions. 1
• Do not delay preventive therapy in patients requiring acute treatment more than twice weekly—early intervention prevents progression to chronic daily headache. 2, 9